Q4105 prior authorization | Anthem Blue Cross Blue Shield of California

Q4105, Integra Dermal Regeneration Template (DRT) or Integra Omnigraft dermal regeneration matrix, per square centimeter, is on the Anthem Blue Cross Blue Shield of California PPO prior authorization list. Not a coverage or referral decision.

Code: Q4105
Description: Integra Dermal Regeneration Template (DRT) or Integra Omnigraft dermal regeneration matrix, per square centimeter
Source: California PPO Prior Authorization List, Pg 170 Original policy

Anthem Blue Cross Blue Shield of California prior authorization

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